New and persistent sedative prescriptions among older adults after critical illness: a population-based cohort study

Background — ICU survivors often have complex care needs and can experience insufficient medication reconciliation and polypharmacy. It is unknown which ICU survivors are at risk of new sedative use post-hospitalization.

Research Question — For sedative-naïve older adult ICU survivors, how common is receipt of new and persistent sedative prescriptions, and what factors are associated with receipt?

Study Design and Methods — Population-based cohort study of ICU survivors ≥66 years who had not filled sedative prescriptions ≤6 months pre-hospitalization (sedative-naïve) in Ontario, Canada (2003 – 2019). Using multilevel logistic regression, we described demographic, clinical, and hospital characteristics and their association with new sedative prescription ≤7 days of discharge. We quantified variation between hospitals using the adjusted median odds ratio (aMOR). Factors associated with persistent prescriptions (≤6 months) were examined with multivariable proportional hazards model.

Results — 250,428 patients were included (mean age 76, 61% male). 15,277 (6.1%) filled a new sedative prescription with variation across hospitals (2% (95% CI 1-3) to 44% (3-57)); 8,458 (3.4%) filled persistent sedative prescriptions. Adjusted factors associated with a new sedative included: discharge to long-term care facility (aOR 4.00, 3.72-4.31); receipt of inpatient geriatric (aOR 1.95, 1.80-2.10) or psychiatry (aOR 2.76, 2.62-2.91) consultation, invasive ventilation (aOR 1.59, 1.53-1.66), and ICU length of stay ≥7 days (aOR 1.50, 1.42-1.58). The residual heterogeneity between hospitals (aMOR 1.43, 1.35-1.49) had a stronger association with new sedative prescriptions than Charlson comorbidity score or sepsis. Factors associated with persistent sedative use were similar with the addition of females (sHR 1.07, 1.02-1.13) and pre-existing polypharmacy (sHR 0.88, 0.80-0.93).

Interpretation — One in 15 sedative-naïve older adult ICU survivors filled a new sedative ≤7 days of discharge, of whom more than half filled persistent prescriptions. New prescriptions at discharge varied widely across hospitals and represent the potential value of modifying prescription practices, including medication review and reconciliation.